Republic of the Philippines Republic of the Philippines Republic of the Philippines Republic of the Philippines Republic of the Philippines

Professional Regulation Commission Professional Regulation Commission Professional Regulation Commission Professional Regulation Commission Professional Regulation Commission
Manila Manila Manila Manila Manila
REGISTRATION DIVISION
APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD
NAME: _____________________________, ______________________________ _________________
Last Name First Name
FOR PRC PROCESSING
Amount:________________________ O.R. No. :___________________________
Date: __________________________ Issued by: ___________________________
YLP FROM: ____________ TO: ____________P/ _____________
SURCHARGE:______________
TOTAL AMOUNT:______________
VERIFIED AND ASSESSED BY: ____________________________
Middle Name
Paste here
your recent
PASSPORT SIZE
colored picture in
white background with
complete name tag
RENEWAL
DUPLICATE
REPRINT
CHANGE OF NAME
PERMANENT MAILING ADDRESS: _____________________________________________________________________________________
DATE FILED: ______________________________ PROFESSION:______________________________ EXAM DATE: __________________________
REGISTRATION DATE: _____________________ LICENSE NO: _______________________________ EXPIRATION DATE: ______________________
CITIZENSHIP: ______________________________ BIRTH DATE: _______________________________ TEL. No./CP No.__________________________
This is to certify that all the information above are true and correct.
(mm/dd/yy)
(mm/dd/yy)
SIGNATURE OF LICENSEE
___________________________________
ID CLAIM SLIP
ISSUED BY: __________________________________
DATE FILED: __________________________________
Please present this slip to claim your professional ID on _____________________________________________ at Window _______________________.
(NOTE: REPRESENTATIVE WITH PROPER IDENTIFICATION SHOULD PRESENT SPECIAL POWER OF ATTORNEY/AUTHORIZATION LETTER FROM
THE REGISTERED PROFESSIONAL AND THIS ORIGINAL CLAIM SLIP.) FOR CONFIRMATION PLEASE CALL UP (02) 736-22-48.
NAME:
OR NO. PROFESSION:
AMOUNT
LICENSE NO. DATE PAID
(mm/dd/yy)
(mm/dd/yy)
APPLICATION TYPE: RENEWAL DUPLICATE REPRINT CHANGE OF NAME
PRC REG Form No. 003 (Rev. Sept 2002)
(mm/dd/yy)
TO BE ACCOMPLISHED
PERSONALLY BY THE
PROFESSIONAL
PLEASE FILL OUT THIS CLAIM SLIP
PROCEDURES
Step 1. Present duly accomplished form together with the requirements at Assessment Windows
Window 16 Window 18
Step 2. Pay prescribed fees at the Cashier
Step 3. Get your claim slip at Windows 16, 18 and 30
Step 4. Claim your professional license as scheduled. Please refer to your claim slip for
further instructions.
REQUIREMENTS
1. Duly accomplished form
2. Two (2) pcs passport size picture: close up, colored, white background with complete name tag
3. Photo/xerox copy of recent professional ID card
4. In case of LOST professional ID card which is still current, the applicant shall submit
notarized Affidavit of Loss
5. In case of DESTROYED professional ID card, the applicant shall surrender the
destroyed card
NOTE : As the authorized representative, I assume direct and full
responsibility/liability for the security of the professional ID.
Signature over Printed Name of REPRESENTATIVE
SPECIAL POWER OF ATTORNEY SPECIAL POWER OF ATTORNEY SPECIAL POWER OF ATTORNEY SPECIAL POWER OF ATTORNEY


KNOWN ALL MEN BY THESES PRESENTS:

I, ________________________, PICPA Member, of legal age, Filipino, resident of
__________________________________ do hereby name, constitute and appoint
ERNESTO C. VALLEJO JR., PICPA MMR Liaison Officer, likewise of legal age, with
office address at 700 Shaw Boulevard, Mandaluyong City to be my true and legal
representative to act and in my name and stead and to perform the act of filing and
claiming my PRC ID in Certified Public Accountants from the Office of Professional
Regulation Commission.

HEREBY GRANTING unto my representative full power and authority to execute and
perform every act necessary to render effective the power secure the aforementioned permit,
as though I myself, have performed it, and HEREBY APPROVING ALL that he may do
by virtue hereof with f ull right of substitution of his person and revocation of this instrument.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _________ day
of _____________________, 2011 at Manila, Philippines.



________________________
PICPA Member

CPA# ______________



ACKNOWLEDGMENT

Republic of the Philippines)
City of Manila )SS

BEFORE ME, a Notary Public for and in Manila, on this _________ day of
________________, 2011 with community tax certificate no. __________ issued on
_____________ at ______________, known to me and to me known to be the same person
who executed the foregoing instrument and acknowledge it to me that the same is their free
act and deed.

WITNESS my hand and seal.


Doc. No. __________
Page No.__________
Book No. __________
Series of __________